The
LINCOLN   FORD   MERCURY
Doctors
Beechnut Auto Repair of Houston
Tune-up Software

"Let The Lincoln / Ford / Mercury Experts Do It Right The First Time"

WEB DIAGNOSTIC CONSENT FORM

Please fill out the form below and submit to authorize a diagnostic assessment for your vehicle. Payment information must be received by phone, fax, or text before work begins on the vehicle.

Equipment Usage Fees - This helps us to help you by purchasing or maintaining newer equipment to stay in compliance with federal laws to help keep our air and water cleaner and safer for all of us.

Test Drive consists of driving the car for ride, feel & operation before and after repair or diagnosis, and/or to relearn or reset idle & air/fuel monitors that may need to be reset.

If the customer requests, we will clean & wash the vehicle outside, vacuum inside, clean windows in & out and wipe the car off. We will inspect all fluids for correct levels only if repairs were performed with service.

* REQUIRED FIELD  
   
NAME: *
PHONE #1: *
Phone #2:
EMAIL: *
MAILING ADDRESS: *
CITY: *
STATE: *
ZIP: *
VEHICLE MAKE & MODEL: *
COLOR: *
LICENSE PLATE #: *
V.I.N. #:
Engine Type:
MILEAGE: *
How was it delivered to the shop?
Please list any or all concerns to be diagnosed:

 

Concern #1:
Concern #2:
Concern #3:
Concern #4:
Concern #5:
   
Labor: $105.22
Parts: $0.00
Sublet: $0.00
Tech. Inform.: $8.31
Subtotal: $113.53
Taxes/Fees: $0.83
Total: $114.36

***THIS IS A PRELIMINARY ESTIMATE ONLY BASED ON VISUAL INSPECTIONS & TESTING.***

The charges estimated on this repair represent an estimated* money amount that includes the processes of inspection, testing, analysis, evaluation, diagnosis, repair, & quality control practices to prevent failure or repeat failure of a part or parts, and also to ensure to the best of our ability your family's safety and that of the motoring public in general.

* Package discounts may be applied as a result of multiple labor operations being performed at the same time on the same vehicle for quality control and customer satisfaction reasons.

 

Notice Pursuant to Section 70.001 Texas Property Code:
I am the person, or agent acting on behalf of the person, who is obligated to pay for the repair of the motor vehicle subject to the repair contract. I understand that this vehicle is subject to repossession in accordance with Section 9.503, Texas Business & Commerce Code, if a written order for payment for repairs of the vehicle is stopped, dishonored because of insufficient funds, no funds or because the draw or maker of the order has no account or the account on which it is drawn has been closed.

I AGREE THAT BEECHNUT AUTO REPAIR IS NOT RESPONSIBLE FOR LOSSES OR DAMAGE TO THE VEHICLE OR ANY PERSONAL ITEMS IT MAY CONTAIN.

SIGNATURE:
                    (First Name, Middle Initial, Last Name)
* By typing in your name you are authorizing a digital signature

 

 


Beechnut Auto Repair, 4209 H Street, Houston, TX  77072

You can E-Mail Ray at moonford@aol.com or call: 281-933-6603

Beechnut Auto Home

FORD TRAINED & CERTIFIED
We are a Certified and Recognized "Independent" Repair Facility
Specializing in the Repair & Maintenance of Lincoln, Ford & Mercury Vehicles

Not affiliated with Ford Motor Company, any U.S. Military Branch, or the U.S. Government

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